[How a group of professionals do become a health "team"? The case of the first Family Medicine Groups in Quebec.]. / Comment naît une << équipe >> de soins ? Le cas des premiers Groupes de médecine de famille au Québec.

How a group of professionals, working together since years, do become a team? Surveys and deep interviews of physicians and nurses belonging to the new Family Medicine Groups help to understand modalities, time requirement and main issues of team work, all resulting in satisfaction at work. Data was collected in a multi-method approach led by the Quebec Ministry of health.

Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care.

PURPOSE: On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS: Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS: One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS: The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

[The implications of the hospitalist phenomenon]. / Les implications du phénomène des médecins hospitaliers.

OBJECTIVE: To evaluate the effect of 2 different systems of hospital care by means of a literature review. QUALITY OF EVIDENCE: Many areas remain unclear because several of the studies are opportunistic and report only isolated experiences or simple before-after observations. Few studies are really experimental, and all were conducted in academic settings, which limits their validity outside these settings. MAIN MESSAGE: The evidence supports the use of hospitalists who devote a minimum of 2 months each year to hospital work and practice full-time on the wards. More often than not, costs are reduced and better education for residents is provided with the hospitalist system. An important point regarding quality of care is that mortality rates are similar with both systems. CONCLUSION: Some questions remain unanswered. For example, what is the best type of training for preparing residents for hospital work and what is the best way for physicians to maintain their skills in this area?

Room for improvement: patients' experiences of primary care in Quebec before major reforms.

OBJECTIVE: To investigate variations in accessibility, continuity of care, and coordination of services as experienced by patients in Quebec on the eve of major reforms, and to provide baseline information against which reforms could be measured. DESIGN: Multilevel cross-sectional survey of practice. SETTING: One hundred primary health care settings were randomly selected in urban, suburban, rural, and remote locations in 5 health regions in Quebec. PARTICIPANTS: In each clinic, we chose up to 4 physicians and 20 consecutive patients consulting each physician. MAIN OUTCOME MEASURES: Patients' responses to a self-administered questionnaire, the Primary Care Assessment Tool, that assessed patient-provider affiliation, accessibility, relational continuity, coordination of primary and specialty care, and whether patients received health promotion and preventive services. RESULTS: A total of 3441 patients participated (87% acceptance rate) in 100 clinics (64% response rate). Timely access was difficult; only 10% expressed confidence they could be seen by their regular doctors within a day if they became suddenly ill. Average waiting time for a doctor's appointment was 24 days. Coordination of care with specialists was at minimally acceptable levels. Patients with family physicians recalled them addressing only 56% of the health promotion and preventive issues appropriate for their age and sex, and patients without family physicians recalled physicians addressing substantially fewer (38%). Most patients reported they were highly confident that their physicians knew them well and would manage their care beyond clinical encounters (relational continuity). The exception was the 16% of patients overall who did not have family physicians (34% of patients at walk-in clinics). CONCLUSION: This survey highlights serious problems with accessibility. Improvement is needed urgently to avoid deterioration of patients' confidence in the health system even though patients rate their relationships with their physician highly. Health promotion, preventive services, and coordination with specialists also needed to be improved, and careful thought must be given to the plight of those without family physicians.

[Integrating prevention and promotion in health systems: four realities, diverse similarities]. / L'intégration de la prévention et de la promotion dans les systèmes de santé: quatre réalités, plusiers similitudes.

The Forum Dialogue on national health systems which took place as a satellite meeting of the 2nd International Conference on Local and Regional Health Programmes compared four countries (Brazil, France, Switzerland and Canada) sustain "conditions to integrate prevention and promotion in health systems". Despite the diversity of the four systems presented, several similarities regarding difficulties faced and achievements obtained in the integration process have been extracted, which has allowed highlighting three perspectives of action. It is suggested that prevention and promotion can be integrated into health systems by mobilising the population and health professionals towards prevention, but with the condition that the promotion and prevention sector increase its credibility by developing practices of quality, organisation, discourse, and prevention practices adjusted to the health care context. Finally, exchange between the countries on this subject is the way forward to nourish the thinking and support each other to obtain this desired integration.